Self-Pay Financial Agreement

Biomarker Health is a self-pay practice and does not accept or bill insurance, Medicare, or Medicaid. I pay the price shown at checkout when I purchase; lab panel prices include the Quest laboratory fee. Reimbursement from any insurer, HSA, or FSA is my responsibility, and an itemized receipt is available on request. A lab panel is refundable until my specimen is collected; in-person services are non-refundable once performed. If I am enrolled in Medicare, I will tell Biomarker Health before purchasing.

You have the right to receive a Good Faith Estimate of the total expected cost of any non-emergency items or services. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. For more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.

By checking the box and submitting this form, I agree that my electronic signature has the same legal effect as a handwritten signature.